a. Field of Invention
This invention pertains to a method and apparatus for reviewing, preferably automatically, patient medical records, and to generate a characteristic code for each record that is related to the health of the patient and to medical services provided by a clinician for the patient during a particular encounter. The method and apparatus is particularly useful for generating codes for generating bills to the patient or for a third party, such as a governmental or private health insurance organization.
b. Description of the Prior Art
In this application, the term ‘encounter’ is used to refer to any event between a patient and a clinician associated with the health of a patient. Thus, an encounter may occur at a clinician's office, in the emergency room of a hospital, at a normal bed in the hospital, in an ICU unit, etc. It is well established that any encounter must be memorialized in a corresponding medical record. These records are very important for every person and organization involved, including the patient, the clinician, the facility (e.g., hospital) where the encounter occurs, insurance companies, health organizations and so on. The record provides the clinician with information for providing immediate, as well as future care for the patient; it provides information for other clinicians in a simple and effective mater to insure consistence and continuity and to avoid duplication during subsequent encounters; it provides information useful for monitoring the performance of the clinician and/or health facility; it provides information that can be collected from several locations for statistical analyses used in research and education.
Importantly, the record is the source used to generate billing and to support claims review. The services requiring medical records are generally referred to as Evaluation and Management (or E/M) Services.
The content of medical records has been studied extensively, and has been the subject of guidelines promulgated by several organizations, including the AMA and the CMS (Center for Medicare and Medicaid Services). For instance, the ‘1995 Documentation Guidelines for Evaluation & Management services’ (‘Guidelines’) is promulgated by the CMS and widely used throughout the United States. The actual form of the record may vary from one hospital to another and even from one department to another, within the same hospital; however, as promulgated by the guidelines, a typical record must include a description of the history of the patient, the examination performed by the clinician, and the medical decision reached by the clinician. Each of these components may include a number of topics and subtopics, depending on the illness of the patient and the severity of the illness.
Importantly, CMS also publishes a set of regulations that defines a payment scale to the clinician based on the record. These regulations must be used by any entity applying to the CMS for a payment. The same or similar regulations may be used by other health insurance organizations.
Thus the use of a comprehensive and standardized record has become not only desirable, but mandatory in the field of health care. Typically, the record is generated by the clinician by filling out a standardized form. This form may be several pages long. Ideally, the clinician, or his assistant, can fill in the form during or immediately after the encounter. Alternatively, the clinician dictates the required information, and the record is generated from the transcribed information. In real life, the generation of the record is delayed by several days or even weeks. Once the record is generated, it is stored and/or disseminated as required.
As discussed above, one important function of the record is to provide information that may be used for the generation of the bills. More specifically, the record itself must be used to generate billing code which then determines how much the clinician or the health care facility gets paid by an insurance organization. In addition, the record must be preserved to provide backup for the bills in case of an audit. In most instances the rules or regulations governing billing of health insurers and other organizations, such as Medicare and Medicaid, are very complicated, and they are related to the level of complexity of the services provided for each component of the report. Therefore, the clinician or his assistant may make an educated guess at what the code should be. This approach is not very productive because, if the wrong code is used, the amount paid by the insurance organization is either too high, and the clinician may be liable for a penalty, or too low, and therefore unprofitable.
Large organizations may employ special personnel whose function is to review each record and generate therefrom the appropriate billing code. This approach is expensive, and since the personnel has no medical training, mistakes can be made anyway.
It has also been suggested that billing codes be generated using special computer programs, for example from Medinotes Corporation. However, these programs are always menu or template driven and require a long time to fill out, time that the clinician does not have. Moreover, data entry is performed on a keyboard, and most clinicians do not want to rely on keyboards. Finally, the programs are very complicated and require long and intensive training periods. One such system is disclosed in U.S. Pat. No. 5,483,443, incorporated herein by reference.